Routine inspection·September 19, 2022

On September 19, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID signage posted at the front entrance. LPA met with Assistant Administrator, Matthew Montilla and explained the purpose of the visit. LPA observed the visitor screening log at entry point and Caregiver was able to provide screening log documentation for staff and residents. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 5 resident bedrooms, 2 full bathrooms, 1 half bathroom and 1 staff room. LPA toured all resident bedrooms; 4 were observed to be private and 1 was observed to be shared with beds 6ft apart from each other. LPA observed 2 full bathrooms, and one half bath. All bathrooms were observed to be clean, odor free and were equipped with liquid soap, paper-towels, hand washing sign, trash can with a tight fitted lids, and non-skid mats. LPA observed staff room. LPA toured the dining room and living room to be clear from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed the first aid kit and medications locked and stored appropriately and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps, toxins, and chemicals were locked and stored away and inaccessible to residents. LPA toured the garage and observed washer and dryer in good repair. Extra food supply and 30-day PPE supply was observed to be present. Extra linen was observed to be present. Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, entry procedures, daily monitoring records for staff, residents and visitor. CONT. to 809C During the visit, LPA found that Staff #1 (S1) was not fingerprinted and associated to the facility. LPA Charitra reviewed S1's fingerprint documentation with the Assistant Administrator and observed that S1 does have fingerprint clearance however, is not associated to the facility. Assistant Administrator provided LPA with S1's fingerprint transfer documentation to associate S1 to the facility. This violation results in a civil penalty of $100. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. LPA requests the following forms to be submitted to CCLD by 9/26/22: LIC308 Designation of Administrative Responsibility LIC500 Personnel Report LIC610E Emergency Disaster Plan Administrator Certificate Report is reviewed with Assistant Administrator and a copy is provided with appeals rights. Civil Penalty is also assessed and given during the visit.